Pharm 2 - Nausea/vomiting

Front 1

Nausea is triggered primarily where?

Back 1

At the 5Ht3 (serotonin) receptor within the chemoreceptor trigger zone.

Front 2

Describe exam findings in a pt with dehydration due to vomiting.

Back 2

- increased thirst and dry mouth
- decreased urination
- tachycardia
- poor skin turgor

Front 3

A patient is recovering from 3 days of vomiting. What is your recommendation for foods to begin introducing after liquids are tolerated?

Back 3

- BRAT diet (banana, rice, apple sauce, toast)

Front 4

A patient complains of vomiting x 2 days. You provide an anti-emetic and tell the patient to begin oral rehydration. What do you recommend?

Back 4

- 24 hours of liquids only.
- NO DAIRY
- water with electrolytes (sugar, salt... gatoraid, pedialyte, etc)

Front 5

Pharmacologic therapy for nausea/vomiting includes what 4 categories?

Back 5

1. 5-HT3 antagonists
2. DA antagonists
3. antihistamines
4. cannabinoids

Front 6

You wish to prescribe a 5HT3 antagonist to a patient with severe vomiting due to chemotherapy. You prescribe what?

Back 6

- ondanestron

Front 7

Ondansetron, Granisetron, and dolasetron are all what class of medication? How can they be administered?

Back 7

- 5-HT3 antagonists
- PO, Rectal, IV, IM, or SL(ondansetron)

Front 8

ADRs for 5HT3 blockers are what?

Back 8

- HA
- dizziness
- diarrhea
- abdominal pain

Front 9

Name common DA antagonists prescribed fro nausea/vomiting.

Back 9

- Metoclopramide
- Trimethobenzamide
- Phenothiazines (Prochlorperazine)

Front 10

Describe the MOA of DA antagonists in treatment of nausea.

Back 10

- antagonizes D2 receptors in the CTZ that triggers nausea.

Front 11

At high doses, metoclopromide is both a DA antagonist and ___

Back 11

5HT3 blocker, and also promotes gastric emptying and small bowel peristalsis

Front 12

Describe contraindications to Rx of a DA antagonist with nausea.

Back 12

- GI hemorhage, obstruction, or perf.
- pheochromocytoma
- seizures
- (use with caution in kids)

Front 13

ADRs of DA antagonist include:

Back 13

- Extrapyramidal effects
- restlessness, anxiety, fatigue, hallucinations
- HTN, HOTN, AV block, bradycardia
- agranulocytosis.

Front 14

One of the most common antihistamines prescribed for nausea is ____

Back 14

promethazine

Front 15

Describe the MOA of promethazine in treating nausea.

Back 15

- H1 blocker and antagonizes D2 receptors in the CTZ.

Front 16

A patient is having a reaction to Promethazine. What ADRs should you look for?

Back 16

- dry mouth, dizziness, etc
- Parkinsonian symptoms
- Neuroleptic malignant syndrome
- blood dyscrasias (destruction of various blood cells)

Front 17

Dronabinol is what class of medication for nausa?

Back 17

Cannabinoids.

Front 18

Side effects of dronabinol include:

Back 18

drowsiness, sedation, and increased appetite (MUNCHIES!)

Front 19

What is the function of GI motility?

Back 19

- mix bowel contents
- propel contents caudally

Front 20

How is intestinal motility controlled?

Back 20

- neuronal (vagus, etc
- hormonal

Front 21

Define constipation:

Back 21

2+ of the following:
- straining >25% of the time
- lumpy or hard stools >25% time
- feeling of incomplete BM >25% of the time
- <2 BM in one week

Front 22

Identify Metabolic causes of impaired GI motility.

Back 22

- hypothyroid, hypercalcemia, hypokalemia, and DM

Front 23

Indentify GI disorder causes of impaired motility.

Back 23

- tumor
- IBS
- diverticulitis

Front 24

Describe neurological causes of impaired motlity.

Back 24

- trauma to brain/cord,
- CNS tumor
- Parinson's

Front 25

Define constipation:

Back 25

2+ of the following:
- straining >25% of the time
- lumpy or hard stools >25% time
- feeling of incomplete BM >25% of the time
- <2 BM in one week

Front 26

Common medications that cause constipation include:

Back 26

- Opiates
- Calcium & Aluminum antacids
- Iron
- Ca blockers
- anticholinergics
(antihistamines and antiparkinsonians, TCAs)

Front 27

Identify Metabolic causes of impaired GI motility.

Back 27

- hypothyroid, hypercalcemia, hypokalemia, and DM

Front 28

Indentify GI disorder causes of impaired motility.

Back 28

- tumor
- IBS
- diverticulitis

Front 29

Describe neurological causes of impaired motlity.

Back 29

- trauma to brain/cord,
- CNS tumor
- Parinson's

Front 30

Common medications that cause constipation include:

Back 30

- Opiates
- Calcium & Aluminum antacids
- Iron
- Ca blockers
- anticholinergics
(antihistamines and antiparkinsonians, TCAs)

Front 31

The BEST way to control constipation (at least initially) is:

Back 31

- Drink plenty of water and fluids,
("p" juices- prune, pear, peach)
- Exercise
- high fiber diet

Front 32

Describe the difference between soluble and insoluble fiber.

Back 32

-Insoluble: shorten transit time and increase bulk (whole grains, bran)
- Soluble: moisten stoole, less effect on transit time (fruits, veggies)

Front 33

Psyllium, Methylcellulose, and polycarbophil are ____

Back 33

bulk-forming laxatives

Front 34

Describe the following about bulk-forming laxatives:
a) examples
b) onset
c) MOA
d) Contraindications

Back 34

a) psyllium, methylcellulose, polycarbophil
b) 2-3 days
c) increase volume of stool with water, distending the colon and stimulating increased peristalsis (*Must have adequate fluid intake)
d) stenosis, ulcerations/adhesions, fecal obstruction

Front 35

What is the 1st line treatment for bedridden or geriatric patients with chronic constipation?

Back 35

- Bulk-forming laxatives

Front 36

A patient takes his daily medications in the morning with a glass of metamucil (psyllium) for some constipation he's been experiencing. What is important to inform him?

Back 36

Bulk-forming laxatives can bind with drugs and prevent/decrease absoprtion. These should be separated from other medications

Front 37

Describe uses for bulk-forming laxatives OTHER THAN for constipation.

Back 37

- relief of mild diarrhea (able to absorb water well)
- relief of IBS after several months' use
- decreasing cholesterol (decrease absorption of fats)

Front 38

ADRs of bulk-forming laxatives include;

Back 38

- flatulence, abd distention, GI obstruction

Front 39

An example of an emollient is ___. It's MOA is ___

Back 39

- Emollients: docusate sodium (colace)
- MOA: surfactant brings water into stool and facilitates mixing of materials within intestine (increase H20 and electrolyte secretion in bowels)

Front 40

WHat is the first line treatment of constipation in pregnant women?

Back 40

Emollients (colace) - along with bulk-forming laxatives.

Front 41

Docusate sodium is useful for what patients?

Back 41

- to avoid straining, so after MI, rectal surgery, opiate use
- pregnant women (along with bulk-forming laxative)

Front 42

Contraindications for the use of emollients in a patient are:

Back 42

- fecal impaction
- sxs of appendicitis

Front 43

When are lubricants such as mineral oil indicated?

Back 43

- to avoid straining after MI or rectal surgery (preventative use only, not chronic use)

Front 44

Lubricants work how?

Back 44

- coat stool for easier passage, inhibits colonic absorption of water to keep stool liquidy (may cause anal leaking)

Front 45

Cautions for use of lubricants include:

Back 45

- avoid in elderly due to severe nausea and risk of aspiration
- may result in decreased absorption of fat-soluble vitamins (KADE).
- may cause leaking from anal sphincter.

Front 46

A pt hospitalized for hepatic encephalopathy is constipated. Other medications are not helping, so you want to prescribe ___

Back 46

lactulose - osmotic laxative

Front 47

Describe the MOA of lactulose.

Back 47

Osmotic agent - disaccharide is metabolized by bacteria into LMW acids resulting in osmosis of water to bowel.

Front 48

Lactulose is most commonly used in who?

Back 48

pts with hepatic encephalopathy

Front 49

What is sorbitol? How does it treat constipation?

Back 49

- Osmotic agent
- monosaccharide creates an osmotic gradient and pulls water into bowel when used in 70% solution
- works in 1-3 days

Front 50

Saline cathartics are often identfied by what ingredient?

Back 50

- Magnesium salts

Front 51

Describe the MOA for saline cathartics.

Back 51

- Mg or Na salts increase water

Front 52

Give examples of saline cathartics:

Back 52

- Mg hydroxide (MOM)
- Mg sulfate (epsom salts)
- Sodium phosphate (fleets enema)
- Mg citrate (citrate of mg)

Front 53

How quickly do saline cathartics work?

Back 53

- 30min-6hrs (PO), or 5-30min (PR)

Front 54

Saline cathartics are contraindicates in who?

Back 54

- pts with impaired renal function (due to potential for accumulation)
- CHF
- Na cathartics in HTN pts

Front 55

Describe MOA of castor oil.

Back 55

- metabolized to ricinoleic acid that stimulates secretion of GI/ mucosa.
- decreases glucose absoprtion
- promotes motility,
- Upsets stomach to produce gstric emptying.

Front 56

How does a glycerine suppository work to relieve constipation?

Back 56

- osmosis through rectal wall.

Front 57

A 6 year old is constipated and his mother fears he cannot take anything by mouth without vomiting. You recommend ____

Back 57

glycerine suppository (Safe for kids)

Front 58

Polyethylene glycol can be mixed into what two substances? What is the difference?

Back 58

- Miralax: 17g mixed in H20 x 2 weeks, OK for chronic use, safe for kids, onset 1-3 days
- PEG, GoLytely: used for colon prep before procedures. onset 1 hr, 4L of solution over 3 hours. NOT for chornic use.

Front 59

Identify the two types of stimulant laxatives.

Back 59

- diphenylmethane derivatives (bisacodyl)
- anthraquinone laxatives (senna)

Front 60

Describe how bisacodyl works to relieve constipation.

Back 60

stimulate nerve plexus of colon to increase peristalsis. - not for kids

Front 61

Important ADRs to consider when prescribing bisacodyl are:

Back 61

- don't mix with dairy or antacids
- GI cramping
- electrolyte problems
- PINK URINE AND FECES
- chronic use may damage nervous plexi and result in atonic colon

Front 62

Describe the MOA of senna.

Back 62

- usually coformulated with docusate
- increases peristalsis by neuro method

Front 63

Why are stimulant laxatives ont recommended for chronic constipation?

Back 63

- may cause damage to plexi with long-term use and result in atonic colon

Front 64

A pt presents with brownish colored urine after being prescribed ____. This is a normal side effect of this laxative.

Back 64

Senna

Front 65

Describe the MOA for lubiprostone.

Back 65

- chloride channel activator (increases fluid secretion locally in small bowel by activating chloride channel)

Front 66

Contraindicatons for lubiprostone are ____

Back 66

intestinal obstruction and pregnancy

Front 67

___ is a peripherally acting antagonist of Mu receptors that may be used to treat constipation.

Back 67

Methylnaltrexone

Front 68

A patient with what CrCl should have an adjusted dose of Methylnaltrexone?

Back 68

CrCl <30mL/min

Front 69

Constipation in children is usually due to ___, and cna be treated well with ___

Back 69

1. diet/habits
2. P juices, suppositories, corn syrup, MOM, bisacodyl,
3. may use senna or mineral oil

Front 70

Define acute vs chronic diarrhea.

Back 70

Acute - <3days
Chronic >14 days

Front 71

Why is it important not to immediately treat diarrhea symptoms?

Back 71

- it's usually a healthy response to a pathogen.

Front 72

When should you avoid any antimotility agents in pts with diarrhea?

Back 72

When dysentery or C. diff is possible.

Front 73

A 4-year-old whose parents have declined childhood immunizations presents with watery diarrhea for the past 4 days and has a mild fever. You suspect?

Back 73

- Rotavirus (nearly all infected by age 5)/ Vaccine given orally at ages 2,4, and 6 mos

Front 74

What are the possible classifications of diarrhea?

Back 74

- Secretory
- Osmotic
- exudative
- altered intestinal transit

Front 75

What is secretory diarrhea?

Back 75

- a stimulating substance increases secretion or decreases absorption f H2o and electrolytes.
- large stool volume >1L/day with normal osmolality

Front 76

What is osmotic diarrhea?

Back 76

- Poorly absorbed substances lead to retention of intestinal fluids.

Front 77

What is the difference between osmotic and secretory diarrhea?

Back 77

- Osmotic - contents of bowel are actively pulling water out
- secretory - problem with cells allowing for leakage/dumping of fluid into bowel

Front 78

___ diarrhea is caused by inflammatory disease that discharges mucus, proteins, and blood into the gut

Back 78

Exudative

Front 79

Describe factors that result in diarrhea due to altered intestinal transit

Back 79

- reduced contact time in sm. intestine (resection or bypass surgery)
- premature emptying of colon (due to metoclopromide, erythromycin)
- bacterial overgrowth (incraesed time of exposure may result in bacterial overgrowth)

Front 80

ID 12 types of drugs that can cause diarrhea.

Back 80

1. laxatives 7. Abx
2. antacids w/ Mg 8.ACE inhib
3. antineoplastics 9. Digoxin
4. Colchine 10. Cholinergics
5. NSAIDS 11. PPIs
6. Orlistat 12. H2 blockers

Front 81

What non-pharmacologic interventions shoudl be done to treat diarrhea?

Back 81

- D/c consumptions of solids and dairy x 24 hrs
- With N/V: BRAT diet
- Rehydrate: ORS, LR, D5W, NS
- Maintain electrolytes

Front 82

How can hydration be maintained for patients with diarrhea?
a) <2 yrs
b) 2+ yrs

Back 82

a) 0-100mL after each BM and between if possible
b) 100-200mL/BM and in between if possible
- continue until diarrhea cessation

Front 83

What 7 classes of meds can be used to tx diarrhea?

Back 83

1. Antimotility
2. Adsorbents
3. Antisecretory
4. Anticholinergic
5. Bacterial replacement
6. Enzymes
7. Abx

Front 84

Give examples of anti-motility drugs.

Back 84

- Opiates and derivatives
- Loperamide
- Diphenoxylate
- Paregoric
- Difenoxin

Front 85

Describe the MOA for Antimotility drugs.

Back 85

1. decrease intestinal transit, prolong contact and absorption of water, increase gut capacity

Front 86

Lomotil is an _____ medication that has an onset within ____. It is contraindicated in ___

Back 86

1. antimotility
2. 48 hours
3. infectious diarrhea (all anti-motility contraindicated)

Front 87

How does loperamide work?

Back 87

- anti-motility: acts directly on muscles to inhibit peristalsis and prolong transit time.

Front 88

Loperamide is contraindicated in what pts.

Back 88

- fever >101F
- acute ulcerative colitis
- Abx associated colitis
- Children <2yrs

Front 89

A hospitalized patient has severe diarrhea you suspect C.dif. Which anti-diarrheal medications would you consider?

Back 89

adsorbents, especially cholestryamine

Front 90

Kaolin-pectin, polycarbophil, and attapulgite are examples of ___

Back 90

adsorbents - effectiveness unproven, mostly OTC

Front 91

Describe the MOA of Kaolin-pectin

Back 91

adsorb nutrients, toxins, drugs, and digestive juices

Front 92

a 6-year old presents with tinnitus and other strange symptoms after his mother has been treating him with small doses of pepto-bismol for diarrhea x 3 days. What should you suspect?

Back 92

Reyes syndrome

Front 93

A patient has had an upset stomach for 2 days. You recommend taking bismuth subsalicylate for a couple days to see if symptoms subside. You should let him know about what side effects?

Back 93

- black stools
- black tongue
- salicylism
- increased risk of gout attacks

Front 94

What pharmacologic interactions are important to remember about bismuth subsalicylate?

Back 94

- anticoagulants
- tetracycline
- may interfere with radiologic studies

Front 95

Describe how octreotide helps decrease diarrhea?

Back 95

- blocks release of serotonin, resulting in direct inhibitory effects
- reduces motlility and facilitates water absorption from gut

Front 96

A patient has had severe diarrhea for a significant period of time that is refractory to toher treatmnt. You can try ___ as a last effort.

Back 96

Octreotide

Front 97

What is octreotide "officially" indicated for?

Back 97

- diarrhea associated with metastatic vasoactive intestinal tumor.

Front 98

Serious side effects of octreotide include :

Back 98

bradycardia
hyperglycemia

Front 99

Why does atropine help with diarrhea?

Back 99

- anticholinergic: blocks vagal tone and prolongs gut transit time.

Front 100

A patient with glaucoma should not receive what diarrhea treatment? Who else is this contraindicated in?

Back 100

- atropine
- BPH

Front 101

What is typically used for bacterial replacement in non immuno-compromised patients?

Back 101

lactobacillus

Front 102

A patient with lactose intolerance suffers intense bouts of diarrhea when he consumes dairy. What can be used to treat and prevent his diarrhea?

Back 102

Lactase enzyme replacement

Front 103

What can be given with ORS to help reduce symptoms of diarrhea including volume of output and duration of diarrhea?

Back 103

Zinc

Front 104

Describe the symptoms of traveler's diarrhea.

Back 104

4-5 loose/watery stools per day with cramping, +/- fever, and lasts 3-4 days without treatment

Front 105

Most traveler's diarrhea is ____ and occurs how soon after travel?

Back 105

1. 80% bacterial
2. 90%+ occurs in 1st 2 weeks of travel

Front 106

Who is at risk for traveler's diarrhea?

Back 106

- ingestion of contaminated food/drink
- high risk foods: veggies, unpeeled fruit, raw/undercooked meat
- meals @ home < restaurants
- Small children and 21-29
- type of infection depends on destination, season, type of travel.

Front 107

What may help with prophylaxis of traveler's diarrhea?

Back 107

- dietary education
- bismuth subsalicylate
- antibiotics (may be irresponsible due to developing resistance), cipro largely effective in some areas.

Front 108

The components of tx for traveler's diarrhea include:

Back 108

- cipro
- azithromycin

Front 109

How must C.diff tx be given?

Back 109

PO to get into gut

Front 110

WHat are the main causes of C.dif?

Back 110

IV clindomycin and IV vancomycin

Front 111

What medications are given to treat C.Diff

Back 111

- metronidazole
- vancomycin
- MUST be given PO

Front 112

Describe Symptoms of IBS

Back 112

- Abdominal pain, bloating, distention
- diarrhea symptoms >3/day
- constipation symptoms >3/wk
- Psychological depression/anxiety
- urinary problems
- fatigue
- dyspareunia
- concurrent probs (fibromyalgia, functional dyspepsia, fatigue syndrome)

Front 113

Describe the manning criteria for diagnosis of IBS.

Back 113

- Chronic or recurrent Abd pain x 6+ mos with 2+:
- abd pain relieved by defecation
- abd pain with more freq stools
- abd. distention
- feeling of incomplete evacuation after defecation
- mucus in stools

Front 114

Describe the Rome III criteria for IBS.

Back 114

- recurrent abd pain or discomfort x >3days/mo in last 3 months associated with 2+:
-relieved with defecation
- onset with change in frequency of stool
- onset with change in form of stool .

Front 115

Describe tx for constipation predominant IBS.

Back 115

- stress mgmt and education
- increase dietary fiber and fluid
- add bulk forming laxative, consider antispasmotics
- add Serotonin-4 agonist (tegaserod)

Front 116

Describe tx for diarrhea predominant IBS.

Back 116

- Stress mgmt and education
- lactose and caffiene free diet as well as avoid other causative foods
- add loperamide or other anti-spasmotic
- Add 5-HT3 antagonist (alosetron)
- may be helpful to increase fiber.

Front 117

What is IBS?

Back 117

irritible bowel syndrome